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Old 09-19-2012
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Default Next stage of disease

A 32-year-old previously healthy woman presents
with a 1-week history of severe fl u-like illness
including malaise, fever, headache, anorexia,
sore throat, and severe myalgias. Her
last menstrual period was 3 weeks ago and normal.
On physical examination she has submandibular
and cervical lymphadenopathy, and a
few discrete reddish-brown macules measuring
1 cm on her chest. Her throat is clear. Her
pulse is 72/min, blood pressure is 112/74 mm
Hg, respiratory rate is 16/min, and temperature
is 38.3°C (100.9°F). Results of her vaginal examination
are shown in the image attached with this thread. She has
multiple sexual partners and uses barrier protection
“most of the time.” Without treatment,
the next stage of this disease is clinically characterized
by which of the following?

(A) Condyloma latum
(B) Fibrotic bone lesions
(C) Macular rash over the hands and feet
(D) Painless ulcer
(E) Patchy alopecia
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Old 09-19-2012
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(B) Fibrotic bone lesions
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  #3  
Old 09-20-2012
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The correct answer is B. Syphilis is a chronic
disease produced by the spirochete Treponema
pallidum. Clinically, syphilis is divided into
primary, secondary, and tertiary (or late) stages.
This patient presents with multiple white-gray
hypertrophic papules and nodules in the vulvar
region. This is a characteristic skin fi nding of
secondary syphilis called condyloma latum.
This patient also presents with other features of
secondary syphilis, namely lymphadenopathy,
rash, and her symptoms of malaise, fever, headache,
anorexia, sore throat, and severe myalgias.
Thus, without treatment this patient may
develop tertiary syphilis, the next stage of this
disease. The manifestations of tertiary syphilis
include gummas (granulomatous lesions that
eventually necrose and become fi brotic) of the
skin and bone, tabes dorsalis, and aortic aneurysm.
Answer A is incorrect. Condyloma latum is a
characteristic skin fi nding of secondary syphilis.
This painless, wart-like lesion often occurs
in warm, most sites and is highly contagious
Answer C is incorrect. Rash is the most characteristic
fi nding of secondary syphilis. The
rash consists of small red macular lesions symmetrically
distributed over the body, particularly
involving the palms, soles, and mucous
membranes.
Answer D is incorrect. In primary syphilis a
chancre develops after an incubation period
of 2–3 weeks. This is a painless ulcer with an
indurated base usually found on the vulva, vagina,
or cervix, although it can occur in any
area that comes in contact with infectious lesions.
Not only is a chancre painless, but it
spontaneously heals in 3–6 weeks, which explains
why women may be unaware of the initial
infection.
Answer E is incorrect. A patchy or so-called
“moth-eaten” alopecia is occasionally associasated with secondary syphilis. This condition is
usually reversible with treatment.
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